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General Survey Form 1

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Sanitary Situation Survey 1. Community ______________________________________________________________ 2. Address _________________________________________________________________ 3. Property Owner_____________________________ Phone #______________________ 4. Plat Map Identifier ________________ Acreage ______ Age of Home _______years 5. How long have you lived here? ________years 6. How many bedrooms are in your home? ________ How many live in your home?______ 7. Does your home have any of the following: washing machine garbage disposal hot tub or spa 8. Is your washing machine connected to the septic system? in-ground lawn sprinkler Yes No If “No” where does it drain? _______________________________________________ 9. Is your hot tub or spa connected to the septic system? Yes No If “No” where does it drain? _______________________________________________ 10. Do you know approximately where your septic system is located? Yes No 11. Is there parking or driving over any part of your septic system? Yes No 12. Where does your drinking water come from? Shared well 13. 14. Private well Other____________________________________________ About how old is your septic system? 11-20 years Public system 0-5 years More than 20 years 6-10 years Don’t know Have you ever had your septic system repaired? Yes No Don’t know If “Yes” what was done? _____________________________________________ _____________________ 15. How much did it cost? ________________ Have you noticed any of the following conditions related to your septic system: Wetness in yard (unrelated to rain) Septic discharge Strong sewerage smell in yard Slow drainage of your plumbing Sewage back-ups into home Well water test shows positive for Fecal Coliform bacteria 16. When was the last time that your septic tank was pumped_________, and how much did it cost__________? How often do you have it pumped? __________________ 17. Do you have a water softener? Yes No 1 Sanitary Situation Survey 18. Would you support the formation of a wastewater utility that would care for the maintenance, repair, and even replacement of your septic system? Yes No If “Yes”, how much money would you be willing to pay, per month for this service? $0 19. $5 $10 $15 $20 Map: Show with approximate distances (in feet): buildings, driveways, roads, wells, septic tank, drainfield, ditches, and ponds, etc. KEY Building : Drainfield : -----DF-----Septic tank : ST Well : W ___________________ 30 feet NORTH How far away is the closest drainage ditch (as the crow flies)? Are there areas or lines of greener, taller grass in the yard? Less than 100 ft No Signature of Surveyor 1 ________________________________________________ Signature of Property Owner Half mile or more Yes (show on map: GGR) Are there any wet or spongy places in the yard that have a sewage odor? _________________________________________ A few hundred yds No Yes (show on map: SP) ____________________________________ Signature of Surveyor 2 ___________________________ Date 2